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E&M and Injections: Is this billable?
Our surgeon documented co-planing of the AC joint/distal clavicle. The diagnosis is bone spurs. Does this work support CPT code 29824, arthroscopic distal claviculectomy?
Question:
We have a new patient presenting for evaluation of new elbow pain following a fall. The provider documented a full history, exam, ordered and interpreted X-Rays. Following this evaluation and discussion with the patient, they agreed the best option was to aspirate and inject the joint. The procedure note documents the aspiration and injection of a corticosteroid. Does this meet the significant, separate service rules to report both the E&M and the aspiration/injection?
Answer:
Based on the description of the encounter, KZA recommends reporting the E&M-25 and the injection code (20605) and the J code for the drug. Remember, Medicare requires the JW or JZ modifiers effective July 1, 2023, if the medication was obtained from single-dose package. Review with your private payors if they are following the same requirement.
Rationale:
New problem
The intent of the visit was not the injection.
Full E&M service performed.
Joint decision making with patient on options and to proceed with minor procedure.
*This response is based on the best information available as of 1/30/25.
Extruded Tympanostomy Tube
My surgeon removed an extruded tympanostomy tube from a patient’s left ear under general anesthesia. She wants to code this as 69424-LT for removing the tube. Can you clarify if this is the correct code?
Question:
My surgeon removed an extruded tympanostomy tube from a patient’s left ear under general anesthesia. She wants to code this as 69424-LT for removing the tube. Can you clarify if this is the correct code?
Answer:
Since the tube has moved from its original intended position and no longer serves the intended purpose, it is considered a foreign body. The correct code to report is 69205 (Removal foreign body from external auditory canal; with general anesthesia).
Please review the CPT definition of a Foreign Body versus Implant
CPT Surgery Guidelines for “Foreign Body/Implant Definition.”
“An object intentionally placed by a physician or other qualified heal care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant. An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”
*This response is based on the best information available as of 1/30/25.
TAP Block?
I am new to coding pain management procedures. Please explain what a TAP procedure is and why it is typically performed. I am unfamiliar with this procedure and what CPT code to use.
Question:
I am new to coding pain management procedures. Please explain what a TAP procedure is and why it is typically performed. I am unfamiliar with this procedure and what CPT code to use.
Answer:
Thank you for your inquiry. A Transverse Abdominis Plane (TAP) block is a regional anesthesia technique used to manage abdominal pain. The physician injects a local anesthetic into the plane between the internal oblique and the transversus abdominis muscles during the procedure. The anesthetic blocks the nerves that supply sensation to the anterior abdominal wall, providing pain relief for the patient.
TAP blocks are commonly used for diagnostic purposes, such as differentiating between abdominal wall pain and visceral pain, postoperative pain management after abdominal surgeries, hernia repairs, and appendectomies, or to treat chronic pain syndromes such as chronic abdominal wall pain.
Several CPT codes are available for this procedure, and the use of one will depend upon the documentation in the operative note and whether the procedure is performed unilaterally or bilaterally or by injection or continuous infusion. The CPT codes include imaging guidance when performed, so there is no additional reporting.
TAP blocks reported by injection (s)
64486: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)
64488: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)
TAP blocks reported by continuous infusions (catheter placement is included)
64487: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed)
64489: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed)
*This response is based on the best information available as of 1/30/25.
Modifier for Bilateral Catheterization
Do you code bilateral catheterization codes with modifier 50?
Question:
Do you code bilateral catheterization codes with modifier 50?
Answer:
Catheterization codes below the diaphragm can be coded with bilateral modifier 50, however, catheterization codes above the diaphragm should be coded with modifier 59 on the second code. (ex. Lower extremity 36245-50, upper extremity 36215, 36215-59).
*This response is based on the best information available as of 1/30/25.
Global period for hernia repair
Do all hernia repairs have a 90-day global period?
Question:
Do all hernia repairs have a 90-day global period?
Answer:
No; inguinal, femoral and lumbar hernias have a 90-day global period. However, abdominal and parastomal hernia repairs have no global period, so E/M and other procedures may be separately reported with appropriate documentation the day following the procedure.
*This response is based on the best information available as of 1/30/25.
Is Scar Revision Still Complex Closure?
I have a scar revision for the abdomen and was going to assign CPT 13101. My coding teammate told me this is no longer the current coding recommendation. Is scar revision still reported with complex closure?
Question:
I have a scar revision for the abdomen and was going to assign CPT 13101. My coding teammate told me this is no longer the current coding recommendation. Is scar revision still reported with complex closure?
Answer:
Thank you for your inquiry!
Yes, your fellow coder is correct. At one point, CPT did include scar revision within the complex closure guidelines. However, in 2020, the guidelines associated with closures were changed, and scar revision was removed from the complex closure definition.
To address this change, a coding tip was placed within the CPT book in 2020 stating: “To report scar revision, see the Skin, Subcutaneous, and Accessory Structures, Excision-Benign Lesion subsection codes (11400-11471).”
According to CPT guidelines, scar revision is no longer reported with complex wound closure. Coding recommendations and guidelines are subject to change, so coders must review them and utilize up-to-date coding resources.
*This response is based on the best information available as of 1/30/25.
